SCCM Resource Library-Pro, Con, and In Between: A Single Track to Critical Care Training and Certification

Video Transcription

My name is Gil Allen. I'm moderating this session. I championed this session this year just because we had an active pro-con discussion last year regarding who should be training our critical care providers and whether APPs and providers outside of our own specialty should be training us and how much exposure we should be getting to them.  And Sam had this good idea of really kind of discussing the pros and cons of whether or not we keep things the way they are with people kind of going through medicine, emergency medicine, surgery, and going along their own separate pathways of critical care training or whether we try to really try to focus on merging them together.  So I have our two speakers today. Sam Tisherman from the Maryland Medical Center Shock Trauma and Antoinette Spivitz of Cooper University in Camden, New Jersey. So I thank them for coming and I thank all of you for being here.  Thanks Gil. Part of the background for this is the fact that several years ago the Society put together a task force to look at the future of critical care training and critical care medicine as a specialty. Tony and I were the co-heads of that task force and we have a paper out about this.  And so we thought it would be good to have this debate. I'm not sure whether we flipped a coin or how we ended up with the pros versus cons, but that's the way it is. But hopefully we're not going to speak for all that long. We're going to present the two sides and then briefly kind of touch on what's actually going on at the moment.  But hopefully have time then to have some discussion about where we should be going with all of this. I mean that was really kind of the basis for having this pro-con in the first place. So please, as you get to that, participate. We really want to hear what your thoughts are.  So with that introduction, I have the task of talking about the critical care as a specialty, the con, let our past dictate the future. I do have to disclose a couple things. The views I'm about to express do not necessarily represent the views of the American Board of Surgery.  I am the SCCM rep to the Child and Parental Surgical Critical Care Component Board of the Board of Surgery. And actually as part of that, I also get to represent the Board of Surgery on the Board of Anesthesia's exam committee. So I am not representing either of their opinions, nor am I necessarily going to present my own opinions until later. So we'll see.  And I do apologize to anybody that's in the pediatric world here that we are focusing on adult critical care because that's where the controversy and the issues really lie.  So I'm going to kind of go through a little history of why we got to where we are and why we should just stay with where we are. So medical intensive care units certainly came out of, and it goes farther back to Florence Nightingale and the idea of bringing all the sick patients together to take care of them.  And certainly this became a big issue with the polio epidemic. And you can see the iron lungs. And since then there have been tremendous advances in mechanical ventilation. We have this Engstrom ventilator, which I'm old enough to have actually seen one at one point in time.  The little bird ventilators, which used to be very common in PACUs. Again, way back many moons ago when I was training the bear ventilators. And now we have these fancy-schmancy ventilators that are totally controlled basically by computers within the systems.  And you can dial up basically whatever you want on the ventilator. You can get all kinds of waveforms and information. And it can be very, very complicated.  And then if you think about all the various modes of ventilation that we use from CPAP to volume control, pressure control, pressure support, proportional assist, neurally adjusted, PRVC, APRV, all these sorts of things, to my simple surgical mind, a lot of settings, so many settings, so many knobs, very complicated.  I mean, to me, lungs just kind of go in and out, right? So that's why we have medical intensive care, right? And then medical intensive care has also spread a little bit. I just mentioned a couple possible sort of subspecialty like coronary care units and oncology units that are around.  But it came out of this complexity of ventilating patients in the intensive care unit. And certainly our pulmonary and critical care medicine colleagues are experts at defining and doing research on the basic science of lung physiology, really understanding what the lungs, because it really is more complicated than just bellows going in and out, and managing complex respiratory diseases.  And you have complex data that can come out of our ventilators on a continual basis if you want to, things like pressure volume loops that are way too complex for my surgical mind. But pulmonologists understand this stuff, and they can help us all figure out how to manage patients on ventilators.  The first big proponent of pushing the ideas of medical intensive care units and training in critical care medicine goes back to Hal Weil, Max Harry Weil, who was one of the co-founders of this society. I love this picture with the volunteers, welcome, help us save lives.  But Hal Weil really is kind of pushing the idea of medical intensive care.  So that's medical. Now what about surgical units? So surgical ICUs kind of came out of recovery rooms, because sometimes patients didn't recover that quickly after big operations, or if they went into the operation really sick, they didn't come out any better for a while.  So the surgical ICU started with Walter Dandy, who was dealing with neurosurgical patients, and then certainly Peter Saffer, again another co-founder of this organization, who is an anesthesiologist, and really took the idea of the way anesthesiologists manage patients in the operating room to the recovery room and to the surgical ICU.  So it was one of the first ICUs in the world, the first ICU in the United States.  And certainly from an anesthesia critical care standpoint, it seems relatively intuitively obvious that anesthesiologists are really good at continually monitoring people, managing airways, managing ventilation, managing hemodynamic support, because the patients either come to you when they are sick, or they force them to have to do these things to manage them because of the anesthetics that they use.  So anesthesiologists naturally do this, and they were certainly some of the first trainees in the critical care world.  What about surgeons?  Well, surgery has come a long way.  Certainly the general surgical ICU has now been sub-specialized into various types of units.  Cardiac surgery, understanding what goes on with somebody that goes on a heart-lung machine and comes off, and now comes to the ICU.  So that's an important sub-specialty of surgery and surgical critical care.  Transplant, it's a big deal. If you take somebody's liver out and you put a new liver in them, there are certain things you need to know about managing those types of patients.  Same with trauma, and trauma patients are very, very different than other types of critically ill patients.  Neurotrauma, brain injury is way more complex than we used to think it was.  And burn patients are very sub-specialized too, very specific issues that they have.  So all these sub-specialties of surgery have grown out of our ability to operate on sicker patients, do bigger operations, and then we've got to take care of them afterwards.  So surgical critical care is coming from the operating room, and this is what the operating room looked like when I was a trainee.  You're supposed to laugh a little, at least a little bit.  I'm making sure you guys are awake, okay?  But now we have these fancy hybrid operating rooms, there's all kinds of information, there's all kinds of other stuff going on there.  So the operating room itself has really changed a lot over the years.  And some of my surgical colleagues have said in public forums, it's not called surgical for nothing.  And on the surgery side of co-founders of this society, as well as Shoemaker, and he really pushed the idea of surgical critical care,  and certainly surgeons are in the best position to understand the anatomy of what they're doing to a patient,  or what's happened to a patient from a trauma setting,  and understand the pathophysiology of what we do to patients and what that's going to mean for them afterwards.  And so this is one of the great pictures of the three of them together, Weill, Shoemaker, and Saffer,  when the society was getting started almost 50 years ago now.  And we always talk about how they were really seeking multidisciplinary critical care,  but maybe it wasn't quite like that.  Maybe they were trying to protect their own specialties.  You know the old saying of keep your friends close, keep your enemies closer.  So maybe they were each trying to keep their niche by kind of being in on bringing together a so-called multidisciplinary society.  Along the way, neuro has become another issue.  There are a lot of neurointensive care advances that have come on.  Back when I was a student, I mean neurologists did a great job of diagnosing things, but then they couldn't really do anything about it.  Now there's a whole lot of interventions that they're doing for stroke, for hemorrhagic stroke, managing status,  neurotrauma.  So this has really become a bona fide specialty within critical care.  And they've come up with all kinds of neurologic monitoring.  There are various ways to monitor intracranial pressure, monitoring flow of transcranial dopplers,  looking at images of CT scans and MRIs.  I mean, I'm not a neurointensivist, but those images look bad.  So this has become another bona fide specialty of critical care.  And so now we have neuroscience ICUs.  I've always thought that was kind of funny that oftentimes they're called neuroscience ICUs.  It's like, our other ICUs aren't science either.  It's only the neuroscience ones that are science.  So there are neuro ICUs, there are neurotrauma units, and again, subspecialties based upon changing management of a very focused group of patients.  And with that has become neurocritical care training. There's the Neurocritical Care Society and the United Council of Neurologic Subspecialties,  who came together to put together an examination system and certification for people who are really interested in neurocritical care.  Similarly, the Society of Neurologic Surgeons, Committee on Advanced Subspecialty Training, or CAST,  has come up with a training program and examination for neurocritical care.  So that's kind of where we are now. Critical care is not just critical care.  It's subspecialized based on the basic problems with the patients and the very advanced types of training that's required to take care of those types of patients.  So you've got pulmonary critical care, you've got surgical critical care, anesthesiology critical care,  and anesthesia and surgery certainly, obviously overlap because they're dealing with the operating room, and neurocritical care.  So if it ain't broke, don't fix it. Don't fix it.  So why are we even thinking about changing this?  It's working fine.  Well, all right, let's step back for a second.  What do the boards have to say about this?  So in 1972, the Society of Critical Care Medicine, along with the boards of surgery, anesthesia, medicine, and pediatrics,  went to the American Board of Medical Specialties and said,  hey, let's get a special certificate in critical care.  It's a single thing coming from all these boards.  Inappropriately, the ABMS said, denied.  Because you guys are so specialized, you should stay that way.  They tried again.  In 1979, they got approval to kind of try to do this,  and put together this Joint Committee on Critical Care Medicine.  This had the Board of Anesthesia, Internal Medicine, Peds, Surgery,  and things were coming along swimmingly until the ABIM said, let's keep the subspecialties going.  Of course, they were right.  Keep the subspecialties going.  They applied for a certificate of special qualifications in 1983,  and this whole Joint Committee thing was disbanded.  And voila, in 1985, we have certificates from the Board of Anesthesia,  the Board of Internal Medicine, Pediatrics, and Surgery.  Keeping those subspecialties going.  Now, along the way, I'll comment for my emergency medicine friends in the audience.  ABM kind of got left out.  They were denied access to this directly,  and many people did training in the U.S.,  but then took the European exam to get the European Diploma in Intensive Care Medicine.  UCNS, for the neurologic side,  at least for a long time, if not from the very beginning,  allowed EM people to take their exam.  But recently, there's been approval for the ABIM, ABS, and ABA to have emergency medicine people do their fellowships,  but they're still in the subspecialties.  So basically, as an emergency medicine person doing this,  you've got to pick which silo you want to be in,  as it's appropriate, because we should be siloed.  It's dangerous to walk between silos.  So this is why we have these silos of medical care, anesthesiology, surgery, and neuro.  And I'm sure Dr. Stivas will try to make an argument to it.  There's a lot of commonality amongst the requirements for these boards  and the core content outline of the exams,  but I'll point out there are some very important differences  that need to be taken into account, like anesthesiology.  There's way more discussion about sedation, delirium, echocardiography,  hepatic encephalopathy, medicine, detailed electrolytes. I mean, if you look at the core content for surgery, it's like abnormal electrolytes.  That's it. We're simple surgeons.  But in medicine, it lists every single possible electrolyte  that can be messed up in the ICU, so it's important to know all that stuff.  Toxic congestion is not touched in surgery.  Hepatopulmonary, portopulmonary syndromes.  Neuro, clearly things like neuroimaging, EEG interpretation.  I mean, all I know about EEGs is that if it's flat, that's really bad.  If it looks like VTAC, that's also really bad.  If it looks like it's really sharp and it would hurt to sit on it, that's kind of bad.  And that's kind of it.  I understand there's more to it than that, but that's why we have neurointensives.  And surgery, certainly, we understand what goes on in the operating room,  so we can manage the problems that we create by doing what we do in the operating room.  And there are neuroendocrine effects, hormonal effects of doing operations on people  and trauma that we understand as surgeons.  Pediatric surgery is only kind of mentioned under the surgery.  And just an example of some of the content differences,  similar to my comment on electrolytes.  If you look at pneumonia under the surgery exam,  it's bacterial or it's fungal or viral.  That's it.  Internal medicine, now you get into some real details.  Typical, atypical, aspiration, aspergillus, non-aspergillus,  really complicated, too much for me.  It's a consult ID if you need them.  So those are some of the differences.  There are important differences between what is required for the training  and what's on the examinations.  Another global issue is the operating room.  So to the internist, the operating room is some black box  where the surgeons did something.  But as surgeons or anesthesiologists, we know what that something is.  We know what that means to the patient.  What are the things that the surgeon is going to be worried about? What are the potential complications?  And so, again, that's where surgical critical care  is different than medical critical care.  Now, there are some other arguments against the common exam.  Again, YA fix was not broken.  The quality of education is quite good from all of these specialties.  It's just sub-specialized.  Critical care training is well aligned with primary residency training.  So if you spent five years learning from surgeons in a surgical residency,  of course you should spend another year or two learning from more surgeons.  That's the way it should be.  Just keep on going.  Another thing, actually, which is kind of an important question,  is career choice.  I mean, a lot of people spend part of their careers  doing something other than working in the ICU.  If you had a primary specialty of critical care, that's it.  No other options. As opposed to, if you do surgical residency and now you do surgical critical care,  you could still operate, do general surgery, or do trauma surgery, or something else.  Or if you're an anesthesiologist, do some anesthesia.  So you lose that kind of potential practice and career flexibility.  And certainly, with a common exam, common training,  you risk developing a jack-of-all-trades, master-of-none,  who can complete 80% of half the list of some of the jobs that need to be done.  Now, actually, I will finish this with some data to back up my argument.  So this is sort of a natural experiment that occurred at a specialty hospital in the UK,  where they were prepping for a brand-new hospital,  and they were going to take these four specialized ICUs and combine them into one.  And while this construction was going on,  the sub-specialized intensivists got moved around to the other ICUs.  So over a six-month period, they spent six weeks in a different ICU  than they had been working in prior to this plan for the move.  They called the people who were working in the regular ICU, the home intensivists,  and the people who were working in an ICU that was not the usual one,  the visitor intensivists.  What happened to the patients?  The visiting intensivists killed patients. Mortality was higher when the visiting intensivists were around.  So again, keeping those silos, those sub-specialties actually were better for patients.  So finally, maintain the status quo.  Hit the easy button. It's easy.  There's no financial costs. There's no political costs.  And, as my koala friend says,  what do you mean we have to change? We've always done it this way. That's certainly the surgeon view of the world.  I've done this since my training. I'm going to keep doing it.  So I pause it to you. There's no reason to make any change.  Thank you very much.  So I think that Sam has done a great job of already explaining to you why we need to change.  So thank you. I could probably just sit down at this point.  In terms of conflicts, I have none.  The views that I have are my own views,  and the views of open-minded, forward-thinking people  who want to change critical care for the best.  So this is Sam and I, and Sam's presented his.  I spent a little time on this talk just reading up on  how I should actually win my arguments.  And, as I said, I think Sam's done a nice job in explaining to you  why we shouldn't maintain this siloed, antiquated approach any further.  But he is right. Change is really hard.  But I think we have to look at the fact that, yeah,  it's hard to do new things. It's hard to change up training.  But, really, we have to focus on how the world has changed in the last, what, 40 years or so.  So I'm going to start by telling you why I'm right,  and hopefully you'll agree with me.  So the current state. Sam did go through this, right?  We have multiple pathways in training to get to critical care right now.  And I'm just going to focus on kind of the general medicine,  surgery, anesthesia. That's not to leave anyone out. It's simply just not to go on and on about all of the differences  and make this a little faster and straightforward.  There are multiple exams, as he said.  There's not one defined curriculum.  I feel really proud to be medicine right now,  because us medicine doctors know so much more than those surgeons.  And so we have this very siloed approach, as he said.  Excuse me, I have a bit of a cough. I'll try to get around that.  But we in the United States, although we think we always do it the best,  we don't necessarily do things the best way, right?  And we are really the only ones who have this very siloed approach left.  If you look at Europe, they all came together.  They created the COBITRIS document.  They defined what the different things that a critical care specialist  should know and do, and that's what everyone follows. Other countries have done similar things.  So we're alone out there in the minority.  It's probably time for change.  I put up this long, boring slide because Sam told you about the fact  that the different specialties, they were trying to come together  and get everyone to agree. No one could agree.  And so they went to the ABMS, the American Board of Medical Specialists.  And these are their rules. This is cut and pasted from their rules.  So this first slide is just some of the basic stuff.  But these last two are what I want you to look at.  One board to promote public and professional understanding  that there's a single standard for preparation and evaluation  of expertise in each specialty.  Only one medical specialty board will be recognized.  So they didn't even pay attention to their own rules  when they allowed critical care to be medicine, surgery, anesthesia,  blah, blah, blah, blah.  And then the distinct training, if you read that,  it goes on to talk about the same thing.  So back when the ABMS did this, I think it really was just  path of least resistance.  You want one? Okay, you can have one.  You want one? You can have one too.  But it's not following their rules.  And I'm saying that I don't think this makes a lot of sense.  So if you were to really think about, if we were to redo this today, would we do it this way?  I'm not so sure that we would.  I think that there's time to redesign, to really think about  what is critical care? What does it look like?  Now, Sam seems to think that patients come in with a tattoo  that says medical ICU or a tattoo that says surgical ICU.  But I think that those of you who practice critical care  from whatever discipline realize that the patient who crashed  their car into the tree could be a drug overdose, Sam.  So you should probably learn how to take care of drug overdoses.  The medical patient who came in with a pneumonia  may actually develop the acute abdomen or abdominal compartment syndrome.  And we medicine people actually need to know how to manage that.  So yes, there are some different things that you're going to come across.  The neuro patient might develop pneumonia  or have those horrid electrolyte abnormalities.  And so, again, you don't have patients who really fit into  these very specific buckets.  But rather, I posit that it's one bucket.  And that's what we all need to...  Oops, I just went backward.  That's where we need to come from.  So as this slide says, is there really medical sepsis,  surgical sepsis, anesthesia sepsis?  Or is it really the common entity that we should all  really learn how to manage and care for these patients  in the best possible way?  So where are we now?  I think I...  There we go.  The realities of training.  Things have certainly changed, as I say, in the last 40 years or so.  And these are some of the perhaps equally as important reasons  as to why we should change what we're doing.  Medical school education is costly.  I'm going to show you a slide about that in just a second.  It takes too long. Right?  Right now, you do your four years of medical school.  You do your five or six or even seven sometimes, right?  Years of surgery.  And then you do another fellowship.  If you're doing medicine, you do three years of medicine.  Then you do a fellowship.  It's at least five years to get done.  For surgery, maybe eight years.  It's a long time.  And so when we look at the cost and the time,  and then we look...  Oh, wait a second.  Let me go back for a minute.  We look at the physician shortage issue.  There's tons of...  I mean, look in any paper.  Look in any journal.  There aren't enough of us.  And yet there's an increasing population of sick patients.  So there aren't enough of us. And there's, as I say, specifically a need for intensivists.  This is a slide on medical school debt.  This goes to 2016.  Look at your median cost of four years of education.  Like $250,000 median.  Four years old.  So probably the numbers here are higher.  So again, you've got people who have got debts of $200,000 to $400,000 who now are in training for 10 years or eight years or whatever it is.  It's just not sustainable.  And then the intensivist shortage.  As I said, there's no lack of data saying that there are not enough intensivists.  So we can't just keep saying, you know, la, la, la, la, right?  We have to look at how do we make change?  How do we stand up and solve the problem?  And so that's where I think we're at.  So what do we do?  Well, we can listen to Sam and do nothing.  Because everything is fine, apparently.  We can talk about commonalities.  And I was doing a roundtable earlier this morning  where we were talking about an all-in for the match.  And some of the people there who were from Pittsburgh,  where Sam practiced, some were from Emory. And they were talking about the fact that although they do have  separate entrances, you know, from surgery, from medicine, from anesthesia,  they really do work as a common team.  So that medicine rotates with maybe a surgeon or anesthesia.  I think that's great.  That's where we were supposed to be.  And I understand that Sam actually designed that.  So remember that.  So we do have programs where that is happening.  But I'm not sure, and this is because I really don't know,  how many programs that really happens.  And if we follow some of the rules of the RRC,  you know, I can't have as a medicine program  a surgeon as my core faculty. Right?  I think that surgery is actually a little better  in allowing other specialties to be core faculty.  Medicine isn't.  I don't agree with that.  I think that the beauty of critical care  is that we have people from different specialties coming to it.  But nonetheless, we have to change some of those rules.  So we do have some programs where what I'm talking about  is actually happening. So we could get to a point where we agree on a common exam.  Right?  That there is actually a common body of knowledge.  If the surgeons want to be stuck in the fact  that there is their piece of it,  we do have electronic exams these days.  So it wouldn't be that hard to imagine  that you define the core competency  that 80-90%, I would probably say at least 90%, of the knowledge base should be common.  And then if you want your section of,  this is me, this is me as a surgeon,  this is me as an anesthesiologist  or a neurointensivist or whatever,  again, they're electronic exams.  Change that piece up.  So I think that the common exam is really not that hard  if we all came together and thought about it. Surgery and anesthesia do share questions.  Medicine, of course, is out there on their own.  How about a common fellowship?  Well, as I said, some places are apparently doing  not necessarily exactly a common fellowship  but are really spending a lot of time together  in common training.  If we were to get really creative,  should we have an integrated program straight from medical school?  So you would finish your four years of medicine,  excuse me, of medical school,  and then decide you want to do critical care  and have a straight pathway.  I don't know what that looks like.  Is it three years? Is it four years?  It would obviously have to be  a very multidisciplinary sort of pathway.  But I think we should think about it. Because go back to the shortages,  go back to the cost of training these days.  So that's perhaps one of the more radical changes, and maybe that's not where we want to go right now, but I think that a common exam, a common fellowship are certainly one of the places  that we should start to very seriously talk about.  And this isn't new. As he said, back in the eight, seventies, eighties, they did talk about one core body of knowledge.  I wasn't part of that discussion then, so I can't tell you exactly how it fell apart.  And I think some of my pulmonary colleagues were probably part of why it fell apart, right? Because I think that at that time, pulmonary was very worried about critical care.  Again, we're talking 40-ish years ago, so quite a while.  But they were talking about it then. There was a paper done by Mitch Fink  talking about critical care in 10 years, and that was in 2006. Again, talking about the fact that we should have one training program. So we didn't make that,  and in fact, we're really quite late. But critical care is all about multi-professional, multi-disciplinary people coming together to really give the patient the best care.  So to think that we should continue in the silos that we're in, continue the way we're doing it, I think is really just the opposite  of what we embody in terms of what we think and what we do.  So I think the time is now. We should make a change. I think to make no changes, to not make a change, is a disservice to the future trainees in critical care,  and I think also to our patients. Because our patients don't, again, have a medical label, a surgical label. They have disease entities that cross all of those lines.  And I think if we train people appropriately, they should be able to take care of the bulk of critical care.  So, I guess we'll do questions, or we'll, I mean, we'd like to have some discussion on this and see what you all think, so I'll.  Yeah, let's open it to discussion. Thank you.  We're mic'd.  We'll have our speakers sit in kind of this coffee talk format, and then we, I'd like people to come up to the podium, or come up to the microphone to ask any questions.  If I don't see any, maybe I'll just, I'll get the conversation started then. Okay, here we go.  And when you come up, just introduce yourself and where you're from. Sure, I should probably disclose that Tony brought backup.  I work with Dr. Spavitz at Cooper, and I guess I speak as an emergency medicine person, so when I was in medical school, not that long ago,  my advisors told me, don't go into emergency medicine, expect that you can do critical care, because that wasn't a thing, and we could see how rapidly it progressed.  You know, the ABIM joint pathway got solidified when I was a third year, and within less than a half a decade, there was surgical anesthesia, and neuro had always been on board.  So I guess what I would say is that I think that there's been a natural experiment here that's already shown that you can take people  from a common body of knowledge from emergency medicine, and train them into these various specialties. So I think that's one that's informative, that really is fairly new.  But two, you know, I think that we need to expect more of ourselves,  and to Dr. Spivitz's point, the operating room is not a black box to me. You know, I don't operate in the operating room, but I know the anastomotic connections  that my patients come out with. I know what my vascular surgeons are doing, and I ask them, you know, and say, hey, this is a new procedure that I haven't seen before.  Tell me what you're worried about. Let me know what my ground rules are. And I think we just need to, you know, this concept that we can't grow, I think, is a real problem.  Sorry, that wasn't a question. That was mostly just me. No, no, just to your point, Liz, I think that emergency medicine is a good example, right?  And I am medicine, just as the disclaimer.  You know, in medicine, I think the initial thought was how could these EM people who have never done medicine, although you did a few months of medicine,  like how could you do critical care? And we've seen that you can do it quite well, right? So I agree, this has been, we've already kind of looked at the experiment, so to speak.  Yeah, I'll only add that I did not develop the program at Pitt, but I was the director of the multidisciplinary training program at Pitt before I left.  And in spending 20 years in a program where in my ICU, I could have, one week I could have an internist, the next week I could have a surgeon,  the following week I could have an anesthesiologist, a fellow, it was easy to recognize what their core knowledge was from their specialties, but then quickly take all of them  and get them up to the same level as intensivists during their fellowship training. So it's clearly doable to take anybody from any of those specialties  to get to be a good general intensivist.  I'm Jim Beck, I'm from the University of Colorado, and I'm the president of the American Thoracic Society this year. I just wanted to pick up on Tony's point about the exam  and give another example, and that's sleep medicine right now. We've been in discussions with the American Board of Medical Specialties about sleep because you can do medical sleep,  you can do pediatric sleep, now you can do ENT sleep, and it's exactly the model you talked about, that the exam, in my opinion, will likely be some sort of umbrella exam  that's the basics of what you need, and then you'd have a secondary module that would focus on just what you need, just pediatric sleep, just ENT sleep.  And so I think it is a good way to be inclusive, but I do take your point that there should be some core that's common, no matter which training pathway you're coming from.  Thank you. And there are other boards that have done similar things with joint exams between boards, whether it's sports or palliative medicine, where that paradigm already exists.  So it's definitely doable, it's up to everybody to agree to do it.  Fraser McKay, I work at Lahey just outside of Boston  in medical critical care. I have two disclosures. So I did medical school at University of Maryland, and I remember the Trauma Resuscitation Unit  extremely fondly, and I did a sub-I in trauma. I thought it was fun. Crazy place. It's an amazing center, nothing but respect for Dr. Scalia and Deb Stein  and all the other people there. And then I did fellowship with Dr. Jonas Bevitz. So, I don't know, I feel like she did a really great job.  I was just incredibly humbled by what Cooper was able to do for me. I think the important thing to keep in mind, so as an intensivist, I am in the tertiary care center,  ICU with fellows and residents, but our group rotates through community centers too. So we serve at least two community hospitals  where they're open units and they're mixed med surge. And if we're honest about the epidemiology of critical care in the United States,  we know that most critical care in the United States is delivered in the community setting in mixed med surge units. 60% of consults that an intensivist gets  in the American healthcare system are surgical in nature. And around something like 70% of critical care that's delivered in the United States,  a lot of it's delivered by hospitalists who are vocally uncomfortable about giving that care. So when I think about, it's dangerous to walk between silos and silos are great,  and there's a lot of specialization and we should keep that specialization. It's like, okay, like maybe at shock trauma, or maybe if you need to go on circuit or on pump,  maybe there is an extra step that you might need to be proficient at those advanced things, but bread and butter critical care. I mean, we know that part of the workforce question  is being solved by advanced practice providers. That's a solution. I don't think we're asking our advanced practice providers to be specialized in their practice.  Most of their stuff is on the job training or they're like 10 or 15 APP fellowships. So I guess my question is, given the reality of what the American healthcare system is,  is there a practical evidence-based justification for an extremely siloed approach? That's my question.  No. I'm really glad you made the point that you did, though, that I think most of the critical care that's being delivered out there is in smaller hospitals, and it's really tricky  to know, are we going to have a different formula for most of critical care out there  where people feel comfortable with both surgical and medical critical care, but then are subspecialized  within their own center? The study that Dr. Tishman brought up about your home unit and your foreign unit, you have to wonder how much of that has to do with subspecialty-based  training versus just being familiar with the nursing staff that are there and having better and more effective communication strategies that are going on between that staff that's  actually leading to better outcomes. But I see this now, right? We're in a tertiary quaternary referral center for a large network, but we still in Vermont only serve about  a 600, 800,000 people population. And we've been struggling what to do with neurocritical  care because we can't build really an effective business model that can sustain an individual neurocritical care. We all believe that it would be better for neurocritical care, but  our intensivists need to be able to handle these issues, both in the medical and the  surgical ICU, because we can't really sustain a neuro ICU. Certainly in Pittsburgh and New Jersey  and Maryland they can do that, but out even in smaller quaternary tertiary referral centers we  can't do that. I'll give a little better detailed answer than my note. There's no good evidence,  but I think this is a great point about subspecialization. We need general intensivists to fulfill the workforce, because as you say, most of it is in the community mixed  med surge, where right now as a surgeon I would probably not get a job if I wanted to. But the other side of it on the sort of the quaternary care center side, no matter where  we each come from in our primary specialty training, neuro care training, we typically all subspecialize at some point, and that's some on-the-job training. It's just like getting  to know the surgeons you're working with, the diseases you're dealing with. ECMO is a great  example of people at Pitt that are medicine trained or emergency medicine trained, who not  only take care of ECMO patients, but cannulate and do everything else. Same in Maryland. It's  some surgeons, but it's also EM and it's anesthesia. It's all flavors of critical care intensivists who have now subspecialized because they want to take care of ECMO patients.  But that's not governed by a board example. Oh, yeah, that's totally. So I'm saying we all naturally do that, and maybe some of that  could become sort of a tertiary training program of some sort. When people do that, there's  some ECMO types of training programs around, but more often than not it's on-the-job training or subspecializing because you now work in a different unit and you learn the issues  with that type of disease process.  Thank you. Please. Thank you very much. A wonderful conversation. And this kind of conversation is associated  with a lot of feelings because we all work in different sides of ICU, and I apologize if I express my feelings. We're such ARs.  It was difficult in one slide to hurt everybody, and the reason that I'm saying that is that  I am a nephrology intensivist, half as a nephrologist in ICU, half as intensivist in medical ICU.  So as a nephrologist, I go to all ICUs, and I see patients taken care of by surgeons and anesthesiologists and neurologists, and yet I haven't seen anybody who says electrolyte  disorder or haven't seen anybody who says pneumonia. They are actually very good in managing all these pieces of information, and medicine folks, they all do echo nowadays,  along with ultrasonography. So it is not that silo already. It's gone beyond that. The notion that you mentioned in 2006 was brought up by Dr. Fink. He thinks that it's  late because there is a precedence on this kind of training, a critical care umbrella in Australia, and they have a five-year program, one year anesthesia, one year medicine, and  three years of critical care, and their intensivists are actually excellent. And as you know, there  is a journal paper that showed that mortality of sepsis in Australia keeps going down by 1.2 percent per year. Also, last year, they published a paper on major abdominal surgery  fluid management. The same group, exactly the same group. So making that silo hurts us in several different fashions. First of all, we don't grow in things that other intensivists  grow. Second is, so practice-wise, it can hurt us when we need to cover each other or we get overflow patients. Second, in education, a lot of things, if we remain in silo, a lot  of our fellows don't go through appropriate training. And for research, honestly, there  is a lot of things that we can do in surgical ICU or neuro-ICU or medicine ICU if we collaborate  together as a whole force. With the shortage of force in intensive care, it is extremely  important to think about how we can join forces rather than separate ourselves in different silos. I apologize.  Sam and Tony, thank you very much. That was a great presentation. Just for those in the crowd, I want to defend Sam. I think he said his disclaimer was he's not presenting his  own views and having conversed with him multiple times. I agree. None of those were your views. I couldn't even clap for you at the end.  Thanks. So my other disclaimer, I was one of the task force members as the EM representative. I'd  encourage everyone to go read that paper. It does lay out a lot of the discussion that was given today. I think, if anything, probably the downside is we're two years too late of  talking about this since we had our paper come out then. But I'm glad we're talking about it today. I'd also echo the component that was made earlier about the idea of general  intensivists making up the majority of the workforce out there. The one correction someone made earlier, someone said this has been a very quick battle. I disagree with you a  little bit in the sense that, and Sam left this off, but in 1979, ABEM was actually at that original table of those people trying to get critical care as a specialty, and we  were kind of pushed to the side as the EM specialty. So it's been a decades and decades long battle. Now, quickly evolution here at the end. But I want to make sure that that  point is actually stressed.  I guess the part I would bring up now is you showed, Tony, a great slide there, this idea of critical care patients saying medical, surgical, and labeling themselves. You guys  have heard me say this in the actual past, that the ED world used to be that way, that you would walk into an emergency department and you would have to decide if you wanted  to go to the medical side or the surgical side, and that's just unrealistic for patients. And EM realized that this is a unique specialty with a unique knowledge base. Obviously, I  think critical care is very much the same. Critical care is a unique specialty with a unique knowledge base that we should help combine. I think everyone in this room is,  at least I'm hearing a common theme that people support that, which I know we support having worked together closely.  I'm looking forward to tomorrow. So tomorrow there's a session where we finally got all of our boards here together, and I think that will be unique as they talk about maintenance  of certifications. They're looking at the back end of this. But obviously, I guess the step I want to ask to you guys, and I guess to myself, too, and peaks in the crowd, I  mean, yeah, we can continue to do our roots-based approach of multidisciplinary critical care and training at our programs. I do that at Wash U. I know you guys do that at Cooper.  Obviously, Pitt's been a great example of that. But how do we get these board members tomorrow to sit down and not talk about the maintenance part, but how do we talk about  the front side part of this? Because really what we need to work on now is all the things we've talked about in our paper and all that part.  Thank you for introducing my next slide. That was perfect. I did not plan Brian's comments. So yeah, we've talked about this idea that there's a common set of knowledge and skills  that intensivists need, and it's not just medicine, it's not just surgery, it's not just anesthesia, et cetera, neuroemergency medicine.  Actually, that's what I wanted. So Tony presented some of the options from on your far left is sort of where we are now.  Separate exam, separate training, next step, big step could be common exam, as we've talked about, maybe some modularity to it, maybe some primary specialty, but separate  training. Then you get to the idea of common exam, common training, and then finally the notion of a primary specialty, which may or may not be something that makes sense down  the road. So to get to Brian's point, the first baby step that we are doing, this is the Society  of Critical Care Medicine fostering this discussion, is this idea of focusing on common knowledge and skills.  So it is totally coincidental that there's this session that's part of the meeting at 11 o'clock tomorrow with representatives from the various boards talking about considering  certification, maintenance certification, whichever boards call it what. But actually at 1 o'clock tomorrow, as a business meeting, separate from the public  panels, we are meeting with representatives from all those boards, as well as the various neuro people, because it's not all boards on the neuro side at the moment, to talk about  this. If we can get the boards to start talking, and we thought that at least talking about  would not be as politically charged as, let's do a common exam and have it ready to go five years from now.  But let's talk about our commonality in terms of what all of our trainees need to know, whether they need to have the skills, and then maybe the next baby step could be talking  about some commonality of exams. So that is the action that we are currently taking, and it will be a process.  I think tomorrow our goal will be to at least start people talking and come up with a way forward to put together maybe a document that says, here is what we as the critical care  community, so it would be the boards, and then we need to bring in the various societies, the ACGME, RRCs, because everybody needs to be on board with here's the commonality that  we all share. And at least by talking, then maybe we'll work toward common exams. The other thing that's been done to answer your question, so Chris Farmer is the chair  of the ABIM critical care section. So Chris is very much in support of this, and I've presented to that group, because  pulmonary is also involved, and we've talked about what we've just talked about, why we think this is important.  I don't know who's pulmonary critical care here. I did two separate fellowships. I did two years of critical care and two years of pulmonary.  But pulmonary is going to, I think, have a lot to say about this, and I don't know what that will look like.  Maybe what we end up with is that there is more than one path, but you do come to a common, whatever it's going to be, common fellowship or common exam, pointing out the fact that  the knowledge is more common than different. So that's, you know, we've, it seems like we've gone very slowly, and I think we have  gone slowly, but some things have kind of happened in the background that hopefully tomorrow at this meeting we'll have some good discussion.  Do we have time for another? Sure. Yeah. So on a little bit of a different topic, off of the examination and the certification, is back to the training.  And I guess my push is, coming from the emergency medicine side, is flexibility in our two-year training programs.  So one of the drawbacks of the surgical program is that the first year is so prohibitive, but our hopeful, soon-to-be new hire at the University of Colorado, I've just been there  four months, hi, is a woman who is medical-critical care trained. She's emergency medicine, medical-critical care trained, but yet in her fellowship she  had the flexibility to prepare herself to work in the cardiac surgery ICU. She did right heart cast. She did viviacmo. She did, like, you know, a time in catheterization.  She was able to prepare herself in the six or eight months that she had of elective time to the type of job that she wanted to do.  And so one of the benefits of the anesthesia programs and some of the medical programs, especially for EM folks, is this flexibility of getting the core basic critical care that  you need, but also being able to have that time to serve specialists. Thank you. Well, I think that's a great point, in fact, that Marilyn and Dan Haase, who's sort of the EM  person under the Surgical Critical Care Fellowship Program, is going to put together a proposal and send it to the RRCDC to get approval.  I guess it was the board to get approval to use as much flexibility as possible so that people during those two years can get as much time as they can in an ECMO unit because that's  one area of subspecialization that people are very interested in. So I think that's totally something that ought to be on the table as to how do you get the core done,  but then have people start doing this subspecialization. So you're not just doing that when you start your real job. You're doing it as part of your training.  Just a quick comment, again, picking up on something Tony said. I'm boarded in both adult pulmonary and critical care.  But the reason pulmonary may have something to say about this is that on the three medical  schools that I've been in the faculty, the vast majority of the trainees who enter our program are doing it because they're attracted to critical care, not pulmonary.  And if you split it, much like PEDS and critical care is now a separate pathway, there will be people who are very entrenched who will start worrying about a worsening manpower  shortage on the pulmonary side. I agree. And that's why we thought the discussions ought to start with things that are not getting into those politics.  Because I think we could always talk about what should our trainees learn. Some of those things will come up later on.  Even in this day and age, just one quick comment to your point. It amazes me that some residents who are interested in critical care,  depending upon the world in which they're living, get told that they should, of course, you should do a pulmonary critical care fellowship. Why would you do critical care?  And that's something that I would have expected 30 years ago, not today. But you're absolutely right. I think there's going to be a lot to be said from pulmonary. One other thing.  One of the benefits of having a common board or just a common way of training, I think that would be helpful.  I think one of the – and to sort of piggyback on the – I forget your name, but what the gentleman just said.  There's good reason for folks in the pulmonary world, I think, to have concerns. They do a lot of work with pulmonary. I currently teach at a pulmonary fellowship place.  Their training is also different. So ACGME requires only nine or – I think it's nine months of critical care. The pulmonary fellows, they have to do a lot.  They have to – there's a sleep shortage. There's a pulmonary shortage. There's advanced bronchoscopy shortage.  And we talk about what does a pulmonary fellow see in their three years to prep them for two exams versus what a two-year fellowship does where all the focus is on critical care.  So at the end of some fellowships, you have pulmonary fellows who have never covered a night solo.  They've never had to really triage because maybe that's what a lot of the APPs or the attendings do. You have them reading – they're doing their CF months.  They're doing all this other stuff. But they're not necessarily doing a lot of critical care versus people who are in a two-year  or even just a one-year critical care fellowship where they live, breathe, sweat critical care.  And at the end of their training, they've been doing critical care for, I don't know, 20 months, something like that. So there may very well be a difference in what that means.  And I think that's worth a concern on both sides. Yes, sir. Hi. Sorry, one last question. If you go the route of a primary specialty,  how do you design it in such a way that you're just not kicking the can down the road, so to speak?  So now you have a residency in critical care medicine, but if you want to work in a surgical ICU,  you'll now be doing some type of additional training or a fellowship in surgical ICU as opposed – because a lot – I do agree with the common training and the common knowledge.  What I worry about is it seems to be if these fields were stagnant. Each of these fields, cardiovascular ICU, which I work in, I'm the medical director of an oncology ICU.  In the onc world, the treatments, whether it's CAR-T or the new immunotherapies are – it's just exponential. It's exploding.  So how do you balance that type of common training in different fields that are just exploding? So I think that if you did a – so that would have to be designed, right?  But if you did four years, let's say. I think that in four years, you would have time to get the exposure. Are you going to be an expert in every one when you finish?  Maybe, maybe not, but then I think it goes back to the job that you get, where if you're going to work in that unit where you do bone marrow transplants or whatever you do, right?  Then that becomes your expertise, or you're going to work in a unit who does a lot of ECMO. That becomes your expertise. So I don't know.  That's sort of how I would think about it, but I guess you're right. I mean, it could evolve to now you have to do an extra year in whatever it was.  I would sort of hope we didn't do that, but I think that – I think it's a very good point, and I think that I'm guessing that in the end of this,  I think we can probably get to a common fellowship and a common exam. I don't – you know, just my guess. I don't know if we can get to a common training program.  Yeah, it's a great point. If that's all you're doing for four years or whatever the time frame is, you can get that kind of experience.  Another important part of all this is none of us stop learning when you finish your training. Because new stuff comes along.  I mean, CAR-T wasn't around 20 years ago, but I took care of people who got IL-2. That was pretty nasty, too.  So, you know, the fields keep changing, and you're always learning and always adapting, so it's not like it ends when you finish your training program.  But certainly those are the politics that we'll have to deal with if we get toward that. The common fellowship idea is, at least in my mind,  having several years ago been the director of one, that's relatively easy, particularly if everybody's been taking the same exam.  Right now it's a challenge because there are basically different requirements for each of the subspecialties, but it's certainly doable.  Getting the boards to work toward some commonality in the exam is going to be the bigger political leap, I think. Thank you. David Kaufman from Rochester, New York.  I just wanted to say in response to that that if you had a four-year training program, and you guys are kind of saying this,  then you wouldn't necessarily do a rotation in breast surgery. You wouldn't do a rotation in outpatient chronic pain management. So there would be a lot more time to say,  let's design a program where you could be exposed to the new oncologic therapies, where you could be exposed to the cardiology that's inpatient cardiology  but not get the experience of what it's like to be an outpatient cardiologist. So I think there's actually a lot of room for some creativity  with a training program that trains some physicians to do this from the get-go, especially since there are a lot of medical students. I'm an advisory dean for medical students.  There are a lot of medical students that want to do critical care. And just like in the days when we didn't have the I-6 programs  for some of the surgical specialties, there's a drop-off. They can't see doing it after they've been through their primary residencies.  And I think just like you saw with cardiothoracic surgeons, now you can hardly get into the I-6 programs. And 15 years ago it was hard to find surgical trainees  who wanted to go into cardiac surgery after five years of general surgery. So I think there are tremendous opportunities to at least consider what it means  to have at least some places that would allow students who wanted it to go through these integrated kinds of programs. I agree. Thank you. Great. Thank you. Thank our speakers.  And I want to thank all of you because those are great questions. I thought there was a lot of great discussion. And I get a lot out of this. So thank you very much.  Thanks for coming. Thank you.

Video Summary

In this video, two speakers, Sam Tisherman and Antoinette Spivitz, discuss the pros and cons of merging critical care training programs for different specialties. They bring up the fact that there is currently a lack of consensus on who should be training critical care providers and how much exposure they should have to other specialties. They suggest that merging training programs could lead to greater collaboration and a more holistic approach to patient care. However, there are concerns about maintaining the expertise and specialization that currently exists within each specialty. The speakers also discuss the history of critical care training and the different paths that currently exist, such as medicine, surgery, anesthesia, and neurology. They point out that critical care is becoming increasingly subspecialized, which presents challenges for training and certification. They suggest that a common exam and a common fellowship could be potential solutions to address these challenges. Overall, the speakers advocate for a more collaborative and integrated approach to critical care training.

Asset Subtitle

Administration, Professional Development and Education, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Review the history of, and multiple existing tracks for, critical care training in the United States
Discuss the pros and cons of unified critical care training and certification
Assess the pros and cons of moving toward a single critical care residency program

Con: Let Our Past Dictate the Future

Samuel A. Tisherman

Pro: Consolidate All Critical Care Training Pathways Into One

Antoinette Spevetz

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Introduction to the ICU

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Intensivist

Tag Education

Tag Fellowship Training

Year 2020

Keywords

critical care training programs

specialties

consensus

collaboration

holistic approach

expertise

specialization

subspecialized

challenges

common exam

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